Nokea
The nurse is orienting to a hospice organization. Which statement does not indicate a right of the terminal client? The right to:
- A. Be treated with respect and dignity.
- B. Have particulars of the death withheld.
- C. Receive optimal and effective pain management.
- D. Receive holistic and compassionate care.
Correct Answer: B
Rationale: Terminal clients have rights to dignity, pain management, and holistic care, per hospice principles. Withholding death particulars is not a recognized right and may violate transparency.
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Which act protects the nurse against a malpractice claim when the nurse stops at a motor-vehicle accident and renders emergency care?
- A. The Health Insurance Portability and Accountability Act.
- B. The State Nurse Practice Act.
- C. The Emergency Rendering Aid Act.
- D. The Good Samaritan Act.
Correct Answer: D
Rationale: The Good Samaritan Act protects nurses providing emergency care voluntarily, limiting malpractice liability. HIPAA, Nurse Practice Act, or fictional acts don’t apply.
Which action by the primary nurse would require the unit manager to intervene?
- A. The nurse uses a correction fluid to correct a charting mistake.
- B. The nurse is shredding the worksheet at the end of the shift.
- C. The nurse circles an omitted medication time on the MAR.
- D. The nurse documents narcotic wastage with another nurse.
Correct Answer: A
Rationale: Using correction fluid obscures records, violating charting standards, requiring intervention. Shredding worksheets, circling omissions, or documenting wastage is appropriate.
The nurse is caring for a dying client and the family. The male client is Muslim. Which intervention should the nurse implement at the time of death?
- A. Allow the wife to stay in the room during postmortem care.
- B. Call the client's imam to perform last rites when the client dies.
- C. Place incense around the bed, but do not allow anyone to light it.
- D. Do not touch the body, and have the male family members perform care.
Correct Answer: D
Rationale: In Muslim tradition, family (often male) may perform postmortem care, respecting cultural practices. Wife’s presence, imam’s role, or incense are less specific.
The client had a mastectomy and lymph node dissection three (3) years ago and has experienced postmastectomy pain (PMP) since. Which intervention should the nurse implement?
- A. Have the client see a psychologist because the pain is not real.
- B. Tell the client the pain is the cancer coming back.
- C. Refer the client to a physical therapist to prevent a frozen shoulder.
- D. Discuss changing the client to a more potent narcotic medication.
Correct Answer: C
Rationale: PMP can lead to shoulder immobility; physical therapy prevents frozen shoulder, per evidence-based practice. Psychological dismissal, cancer assumptions, or narcotics are inappropriate.
The 6-year-old client diagnosed with cystic fibrosis (CF) needs a lung transplant. Which individual would be the best donor for the client?
- A. The 20-year-old brother who does not have cystic fibrosis.
- B. The 45-year-old father who carries the cystic fibrosis gene.
- C. The 18-year-old who died in an MVA who matches on four (4) points.
- D. The 18-year-old drowning victim who is a three (3)-point match.
Correct Answer: A
Rationale: A healthy sibling (20-year-old brother) offers the best HLA match and living donor potential, minimizing rejection. Carrier status or partial matches are less optimal.